- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,488.00 / $2,488.00 / $2,488.00
| Professional | | $2,488.00 | $2,488.00 | $2,488.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,110.00 / $3,856.00 / $7,962.00
| Professional | | $3,110.00 | $3,856.00 | $7,962.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,975.76 / $4,975.76 / $4,975.76
| Facility | | $4,975.76 | $4,975.76 | $4,975.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,859.20 / $2,859.20 / $3,574.00
| Professional | | $2,859.20 | $2,859.20 | $3,574.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,044.96 / $1,044.96 / $2,488.00
| Professional | | $1,044.96 | $1,044.96 | $2,488.00 |